Nursing Health Assessment: Purpose, Types, Sources cld

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Nursing health assessment: It's Purpose, Types, and Sources

Nursing health assessment: It's Purpose, Types, and Sources

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  • 1. Health Assessment: An Introduction Maria Carmela L. Domocmat, RN, MSN Instructor, Nursing Health Assessment School of Nursing Northern Luzon Adventist College
  • 2. Assessment: An Introduction• Purpose• Types• Sources Maria Carmela L. Domocmat, RN, MSN
  • 3. Who among you looked at yourself in the mirror before going to class today? WE ALWAYS PRACTICE ASSESSMENT IN OUR DAILY LIVING
  • 4. WHAT CAN YOU SAY ABOUTTHESE PICTURES? WHATINFERENCE CAN YOU MAKE?
  • 5. Assessment• the collection of data about an individual’s health state• first and most critical phase of the nursing process Maria Carmela L. Domocmat, RN, MSN
  • 6. Assessment• ongoing and continuous throughout all the phases of the nursing process• is systematic and continuous collection, validation and communication of client data as compared to what is standard/norm Maria Carmela L. Domocmat, RN, MSN
  • 7. Purpose:To establish a data base (all the information aboutthe client) to determine the client’s overall level offunctioning in order to make a professional clinicaljudgmentTo supplement, confirm, or question data obtainedin the nursing historyTo obtain data that will help the nurse establishnursing diagnoses and plan patient care Maria Carmela L. Domocmat, RN, MSN
  • 8. To evaluate the appropriateness of the nursinginterventions in resolving the patients identifiedpathophysiology problemscollect data of patient’s health status, to identifydeviations from normal, to discover the patient’sstrengths and coping resources, to point actualproblems, and factors that place the patient at riskfor health problems Maria Carmela L. Domocmat, RN, MSN
  • 9. • Wholistic data collection.• Nurse collects physiologic, psychological, sociocultural, developmental, and spiritual data about the client Maria Carmela L. Domocmat, RN, MSN
  • 10. nurse focuses on how client’s health statusaffects his activities of daily living (ADL) andhow the client’s ADL affect is health Ex: client with asthma Maria Carmela L. Domocmat, RN, MSN
  • 11. assess how client interact within their family,cultures, and community and how the client’shealth status affects the family and community Ex: client with DM who has amputation; single parent mother of a 6 year-old child Maria Carmela L. Domocmat, RN, MSN
  • 12. • Data from nursing assessment can be classified as subjective and objective. Maria Carmela L. Domocmat, RN, MSN
  • 13. Data include:nursing health historyphysical assessmentthe physician’s history & physicalexaminationresults of laboratory & diagnostic testsmaterial from other health personnel Maria Carmela L. Domocmat, RN, MSN
  • 14. Performing assessment is likecollecting the pieces of a puzzle
  • 15. Assessment– The first step in determining the health status of the client– Because the entire plan of care is based on the data collected during this phase, you need to make every effort to ensure that your information is correct, complete, and organized in a way that helps you begin to get a sense of patterns of health or illness. Maria Carmela L. Domocmat, RN, MSN
  • 16. Types of Assessment Maria Carmela L. Domocmat, RN, MSN
  • 17. Types of Assessment• Initial comprehensive assessment• Ongoing or partial assessment• Focused or problem-oriented assessment• Emergency assessment• Time-lapsed assessment Maria Carmela L. Domocmat, RN, MSN
  • 18. Initial comprehensive assessment• assessment performed within a specified time on admission Maria Carmela L. Domocmat, RN, MSN
  • 19. Initial comprehensive assessment• Involves collection of subjective data about the – client’s perception of his/her health of all body parts or systems, – past health history, – family history, and – lifestyle and health practices (which includes information related to the client’s overall function) as well as objective data gathered during a step-by-step physical examination Maria Carmela L. Domocmat, RN, MSN
  • 20. Initial comprehensive assessmentWhen performed?• On the initial contact with the client• where: hospital, community, clinic or home setting• purpose: to have a baseline comprehensive data about the client• Ex: nursing admission assessment Maria Carmela L. Domocmat, RN, MSN
  • 21. Ongoing or partial assessment Maria Carmela L. Domocmat, RN, MSN
  • 22. Ongoing or partial assessment• consists of data collection that occurs after the comprehensive database is established• consists of mini-overview of the client’s body systems and holistic health patterns as a follow- up on his health status Maria Carmela L. Domocmat, RN, MSN
  • 23. Ongoing or partial assessment• When performed?• usually performed whenever the nurse or another health care professional has an encounter with the client Maria Carmela L. Domocmat, RN, MSN
  • 24. Ongoing or partial assessment• purposes:• Any problems that were initially detected in the client’s body system or holistic health patterns are reassessed in less depth to determine any major changes (deterioration or improvement) from the baseline data.• Brief reassessment of the client’s normal body system or wholistic health patterns is performed to detect new problems Maria Carmela L. Domocmat, RN, MSN
  • 25. Focused or problem-oriented assessment• consists of a thorough assessment of a particular health problem and does not cover areas not related to the problem• purpose: to have a thorough assessment on the special health concern of the client identified in an earlier assessment Maria Carmela L. Domocmat, RN, MSN
  • 26. Focused or problem-oriented assessment• When performed?• performed when a comprehensive database exists for a client and he/she comes to the health care agency with a special health concern Maria Carmela L. Domocmat, RN, MSN
  • 27. Emergency assessment• a very rapid assessment performed in a life- threatening situations• rapid assessment done during any physiologic/physiologic crisis of the client to identify life threatening problems Maria Carmela L. Domocmat, RN, MSN
  • 28. Emergency assessment• purpose: to determine the status of the client’s life-sustaining physical functions Maria Carmela L. Domocmat, RN, MSN
  • 29. Time-lapsed assessment• reassessment of client’s functional health pattern done several months after initial assessment to compare the client’s current status to baseline data previously obtained. Maria Carmela L. Domocmat, RN, MSN
  • 30. Sources of Data Maria Carmela L. Domocmat, RN, MSN
  • 31. Sources of Data• Primary source:• Secondary source: Maria Carmela L. Domocmat, RN, MSN
  • 32. Sources of Data• Primary source: – data directly gathered from the client using interview and physical examination. Maria Carmela L. Domocmat, RN, MSN
  • 33. Sources of Data• Secondary source: – data gathered from client’s family members, significant others, client’s medical records/chart, other members of health team, and related care literature/journals. Maria Carmela L. Domocmat, RN, MSN
  • 34. Maria Carmela L. Domocmat, RN, MSN